1-005 Summary of Forms

The following forms are used by local offices to administer the Social Services Program for families, children, and youth. Instructions for these forms are contained in the appendix at the end of this title:

Form Number	Form Title	Appendix Reference
CWI-1	Parent/Parent Substitute Letters A&B	474-000-1
CWI-2	Parent/Parent Substitute Questionnaire	474-000-2
CWI-3	Provider Letter	474-000-3
CWI-4	Case Plan/Court Report/Review	474-000-4
CWI-5	Permanent Plan Review Summary and Assessment	474-000-5
CWI-6	Post-Conference Report	474-000-6
CWI-7	Review Team Feedback	474-000-7
CWI-10	Child Welfare Information System	474-000-8
DA-18D	Application for Foster Care Assistance	474-000-9
DPW-1	Request for Assistance and/or Services	474-000-10
DPW-19	Client Referral	474-000-11
DPW-46	Authorization for Investigation	474-000-12
DSS-2A	Social Service Exception	474-000-29
DSS-3A	Social Services Application	474-000-30
DSS-3E	Incapacity Statement	474-000-31
DSS-4	Case Information Summary	474-000-33
DSS-4A	Social Services Provider Authorization	474-000-34
DSS-4C	Service Provider Notification	474-000-35
DSS-5B	Social Services Billing Document	474-000-36
DSS-6	Client's Notice of Action	474-000-37
DSS-8	Agency Service Provider Agreement	474-000-38
DSS-8A	Agency Service Provider Agreement Amendment	474-000-39
DSS-9	Individual Service Provider Agreement	474-000-40
DSS-10	Social Service Provider Identification	474-000-41
DSS-0024	Child Protective Services Child Abuse/Neglect Report	474-000-43
DSS-120	Rollodex Card	474-000-44
DSS-0351	Single Family Day Care Self-Certification Checklist	474-000-50
DSS-0363	Child's Record for Child Care	474-000-51
DSS-0851	Day Care Home, Foster Care Home, Group Home Environmental Evaluation	474-000-60
DSS-0853	Medical Report	474-000-61
DSS-0855	Child's Record	474-000-62
DSS-0856	Child Placement and Financial Status	474-000-63
DSS-0857	Voluntary Placement Agreement	474-000-64
DSS-0910A	License Application for Centers, Agencies, Group Homes	474-000-70
DSS-0910B	License Application for Private Homes	474-000-71
DSS-0910C	Monitoring Record	474-000-72
DSS-0911A	Inspection Referral for Centers, Agencies,Group Homes	474-000-73
DSS-0911B	Inspection Referral for Private Homes	474-000-74
DSS-0912	Reference Letter	474-000-75
DSS-0913	Health Information Report	474-000-76
DSS-0913A	Health Information Report for Foster Homes	474-000-77
DSS-0914	Alternative Compliance Request	474-000-78
DSS-0916B	License for Boarding Home and Day Care	474-000-79
DSS-0917A	Report on Non-Compliance with Requirements	474-000-80
DSS-0917B	Child Care Facility Complaint Report	474-000-81
DSS-0917C	Complaint Letter	474-000-81
DSS-0917D	Complaint Referral	474-000-83
DSS-0931	Supplement to License Application for Day Care Centers	474-000-84
DSS-0934	Day Care Center Standards Compliance Review	474-000-85
DSS-0944	Evaluation of Applicants for Approved or Licensed Foster Care	474-000-86
DSS-1151	Homemaker Provider Check List	474-000-100
DSS-1153	Homemaker Weekly Time Sheet	474-000-101
DSS-1154	Homemaker Service Task List	474-000-102
DSS-1226	Emergency Shelter Care Contract	474-000-103
DSS-1227	Emergency Shelter Care Billing Document	474-000-104
DSS-1228	Emergency Shelter Care Request for Extension	474-000-105
DSS-1650	Abuse/Neglect Hotline Intake Form	474-000-106
DSS-1851	Transportation Review Check List	474-000-107
DSS-9911	Registered Family Day Care Homes Referral Form	474-000-109
DSS-9920A	Registration Application and Affidavit	474-000-110
DSS-9920B	Registration Closure Form	474-000-111
DSS-9922	Reference Release Statement	474-000-113
DSS-9924	Rules Compliance Checklist	474-000-114
DSS-AR50	Application for a Child	474-000-130
DSS-AR52	Foster and Adoptive Home Inquiry	474-000-131
DSS-AR54	Approved Adoptive Family Care	474-000-132
DSS-AR55	Referral for Adoption	474-000-133
DSS-AR61	Agreement for Adoptive Home Care	474-000-134
DSS-AR62	Newborn Record	474-000-135
DSS-AR64	Relinquishment for Adoption	474-000-136
DSS-AR65	Relinquishment of Child by Parents	474-000-137
DSS-AS50	Application and Agreement for Subsidy	474-000-138
DSS-AS51	Subsidized Adoption Program Child's Summary	474-000-139
DSS-AS52	Sample Letter for Annual Review of Subsidy	474-000-140
DSS-ICPC-100A	Interstate Compact Application to Place Child	474-000-141
DSS-ICPC-100B	Interstate Compact Report on Placement Status of Child	474-000-142
IRS-2678	Employer Appointment of Agent	474-000-160
PDS-100	Client Identification Data	474-000-170
SS-5	Application for a Social Security Card	474-000-180
SS-1610	Social Security - Public Assistance Agency Information Request	474-000-181
SVP-792	Notice of Redetermination, Delinquent Reviews, and Cases Deleted	474-000-182